Provider Demographics
NPI:1396288551
Name:STACYS WELLNESS PHARMACY INC
Entity type:Organization
Organization Name:STACYS WELLNESS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-474-0600
Mailing Address - Street 1:485 N CHANCERY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-8903
Mailing Address - Country:US
Mailing Address - Phone:931-474-0600
Mailing Address - Fax:931-474-0601
Practice Address - Street 1:485 N CHANCERY ST STE 1
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-8903
Practice Address - Country:US
Practice Address - Phone:931-474-0600
Practice Address - Fax:931-474-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN58993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166501OtherPK
TNQ033117Medicaid